Chronic Low Back Pain (CLBP)
Conditions
Keywords
Manual therapy, Mobilization with Movement, Spine, Mulligan
Brief summary
Objectives: To compare the effects of lumbar sustained natural apophyseal glides (SNAGs) applied in loaded versus unloaded positions on pain, disability, and function in individuals with chronic nonspecific LBP. Methods: A sample of 59 participants was assigned to receive six sessions of standard intervention, with lumbar SNAGs applied in either a loaded (sitting) or an unloaded (quadruped) position. This study was conducted between November 2025 and May 2026. Outcomes measured pre- and post-intervention included pain intensity (VAS), lumbar flexion range of motion (BROM device), and functional disability (Oswestry Disability Index).
Detailed description
Low back pain (LBP) is a global health problem with an estimated lifetime prevalence of up to 80% in adults \[1\]. It is one of the leading causes of disability worldwide and places a substantial burden on health care systems and economies. Although most cases are nonspecific, patients often experience significant pain, restricted mobility, and impaired function, which negatively affect their quality of life \[2\]. The global burden of low back pain remains substantial, particularly among middle-aged adults (45-59 years), with a disability-adjusted life years rate of 747.92 per 100,000 population in 2021. Notably, high body mass index was the only risk factor showing a significant increasing trend (estimated annual percentage change = 1.08) over the past three decades \[3\]. This epidemiological context underscores the clinical importance of our comparison, as loaded SNAGs may be particularly relevant for overweight/obese patients who experience greater gravitational loading on the lumbar spine during daily activities Management strategies typically involve a combination of exercise, patient education, and manual therapy \[3\]. Among manual therapy approaches, the Mulligan Concept - specifically, Sustained Natural Apophyseal Glides (SNAGs) - has gained attention due to its reported immediate effects on pain reduction and mobility. SNAGs are a form of Mulligan concept mobilization-with-movement in which the therapist applies a sustained accessory glide to a spinal segment. At the same time, the patient actively performs the symptomatic movement. Evidence suggests SNAGs can improve pain, lumbar range of motion (ROM), and functional status in patients diagnosed with nonspecific LBP \[4-6\]. A central principle of SNAGs is their application in functional, weight-bearing positions that reflect real-life movement demands. However, physiotherapists sometimes apply SNAGs in unloaded positions (e.g., prone or quadruped) in both clinical settings and research situations. 9,10 Biomechanical research demonstrates that spinal loading alters facet joint kinematics and tissue stresses, suggesting that the clinical effect of SNAGs may depend on whether they are applied in a loaded or unloaded position \[7, 8\]. Despite this, no randomised controlled trials (RCTs) have directly compared these two SNAG modes. This study aims to address this gap by comparing the clinical effectiveness of lumbar SNAGs applied in loaded versus unloaded positions on pain, ROM, and function in patients with chronic nonspecific LBP.
Interventions
PROCEDURELoaded-SNAG
patients will receive SNAGs from standing (Loaded-SNAG), step-stance, or functional position that provokes symptoms. A specialized Mulligan belt was used around the patient's waist and the therapist's hips. The mobilizing force was applied parallel to the facet joint plane (cephalic direction) and over the spinous processes of the respective symptomatic spinal levels. The therapist's hand's ulnar aspect was used over the spinous process of the superior vertebra of the involved segment for flexion glide. The therapist applies accessory glide to targeted zygapophyseal level while the patient actively performs symptomatic movement (e.g., forward flexion), performing repetitions with the therapist maintaining the glide.
PROCEDUREUnloaded-SNAG
patients will receive unloaded SNAG from quadruped position to reduce the axial loading. The therapist applies the equivalent accessory glide at the symptomatic spinal level while the patient performs the symptomatic movement (modified to be non-weight-bearing).
Sponsors
University of Hail
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Masking description
Participants were randomized into either the SNAG-loaded Group or the SNAG-unloaded Group. Randomisation was performed using the permuted blocks method. The allocation process was conducted by a coworker who was not involved in either the assessment or intervention procedures. The outcome assessor was blinded to group allocation. Participants could not be blinded due to the nature of the interventions. The therapist was not blinded for practical reasons. Statistical analysis was performed by an independent analyst blinded to group assignment using coded group identifiers (A and B).
Eligibility
Sex/Gender
ALL
Age
20 Years to 40 Years
Healthy volunteers
No
Inclusion criteria
* Chronic non specific low back pain for 6 weeks or more * Who scored between three and six on a visual analogue scale (VAS) * Restriction of the movement was only in flexion ROM
Exclusion criteria
* Pregnancy, * Obese, * Infectious conditions of the spine, * Autoimmune disorders, * Malignancy * Any contraindication to physiotherapy and manual therapy * Any patient received physical therapy sessions last 6 months
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Pain intensity | 1 week | Visual analogue scale (VAS), which is a 10-cm line, 0 denotes no pain and 10 the most intense agony. |
| Lumbar flexion ROM | 1 week | The BROM is an electronic goniometer that will be used to evaluate the range of motion for trunk flexion |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Functional disability | 1 week | The functional level was assessed using a validated Arabic version of the Oswestry Disability Index (ODI). A total score will be calculated, the percentage of disability (score obtained divided by 50 and multiplied by 100) ranged from 0% (no disability) to 100% (complete disability). |
Countries
Saudi Arabia
Outcome results
None listed